Unfavorable clinical outcomes in patients with good collateral scores following endovascular treatment for acute ischemic stroke of the anterior circulation: The UNCLOSE study

Abstract

Background Patients with acute ischemic stroke secondary to large vessel occlusions and good collaterals are frequently associated with favorable outcomes after mechanical thrombectomy, although poor outcomes are observed also in this subgroup. We aimed to investigate the factors associated with unfavorable outcomes (modified Rankin Scale3–6) in this specific subgroup of patients. Methods In total, 219 patients (117 females) with anterior circulation stroke and good collaterals (American Society for Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grades 3–4), treated by mechanical thrombectomy between 2016 and 2021 at our institution were included in this study. Clinical files and neuroimaging were retrospectively reviewed. Univariate and multivariate analyses were performed to identify the predictors of unfavorable outcomes in the overall population (primary endpoint). Secondary endpoints focused on the analysis of the predictors of unfavorable outcomes in the subgroup of successfully recanalized patients, mortality, and symptomatic intracerebral hemorrhages in the overall population. Results Poor outcome was observed in 47% of the patients despite the presence of good collaterals. Older age ( p < 0.001), higher baseline National Institute of Health stroke scale ( p < 0.001), no intravenous thrombolysis administration ( p = 0.004), > 3 passes ( p = 0.01), and secondary transfers ( p < 0.001) were associated with the primary endpoint. The multivariate analysis showed a predictive effect of modified treatment in cerebral infarction 2b-3 and of first pass effect on symptomatic intracerebral hemorrhage. Conclusions Despite good collaterals, defined through the American Society for Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale, poor outcomes occurred in almost half of the patients. Patients with good collaterals not receiving intravenous thrombolysis were significantly associated with unfavorable outcomes, whereas first pass effect was not significantly correlated with clinical outcome in this specific cohort of patients. Different methods to assess collaterals should also be investigated.